Scribd
Upload
54 views30 pages

Lung Cancer Case Presentation Summary

- The patient is a 67-year-old female who presented with a 3cm nodule in her left upper lung lobe found on CT. Biopsy revealed adenocarcinoma. - She has a history of hypertension, dyslipidemia, and cerebral atherosclerosis. Previous operations include parathyroidectomy and adrenalectomy. - Pre-operative exams showed the lung cancer was stage IA3. She underwent a left upper lobectomy on October 24th for treatment.

Uploaded by

‍우은채[ 학부재학 / 의학과 ]
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
54 views30 pages

Lung Cancer Case Presentation Summary

- The patient is a 67-year-old female who presented with a 3cm nodule in her left upper lung lobe found on CT. Biopsy revealed adenocarcinoma. - She has a history of hypertension, dyslipidemia, and cerebral atherosclerosis. Previous operations include parathyroidectomy and adrenalectomy. - Pre-operative exams showed the lung cancer was stage IA3. She underwent a left upper lobectomy on October 24th for treatment.

Uploaded by

‍우은채[ 학부재학 / 의학과 ]
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd

CS Case Presentation

안암 PK M 조
2018180064 우은채
CASE
PRESENTATION
PATIENT IDENTIFICATION
Identification

Chief Complaint
• Name : 이 * 자
Present Illness

History
• Sex / Age : F / 67
Review of System

Physical Examination

Initial Lab Findings


• Admission date : 2022.10.23
Diagnosis & Plan

CHIEF COMPLAINT
Operation

• 수술받으러 왔어요
CASE
PRESENTATION
PRESENT ILLNESS
Identification

Chief Complaint
• 기저질환 HTN, Dyslipidemia, Cerebral atherosclerosis 로 NU f/u 하던 분
Present Illness

History • 2022 년 7 월 치과 진료 도중 발견한 CT 에서 LUL 3cm nodule 발견됨


Review of System
• 본원 PU 내원하여 PCNB 및 EBUS 시행한 결과 LUL adenocarcinoma 와
Physical Examination

Initial Lab Findings 이와 별개의 2R LN neuroblastic tumor 확인되었음


Diagnosis & Plan
• 10/23 일 폐암 수술 위해 흉부외과 입원
Operation
CASE
HISTORY
PRESENTATION

Identification
• DM/HTN/TB/Hepatitis/Dyslipidemia (-/+/-/-/+)
Chief Complaint

Present Illness • Parathyroid adenoma


History
• Central giant cell granuloma
Review of System

Physical Examination
• Cerebral atherosclerosis
Initial Lab Findings • Admission/Operation : Rt. parathyroidectomy &Lt. adrenalectomy ['22-09-15]
Diagnosis & Plan
• Medication (+)
Operation
✔ NU medi. : losartan, clopidogrel
✔ Trauma (-/-)
• Alcohol, Smoking (-/-, never smoker)
• Family Hx (+, 어머니 뇌경색 )
CASE
PRESENTATION
REVIEW OF SYSTEM
Identification

Chief Complaint
General Fever/Chilling (-/-), General weakness/Fatigue (-/-) Weight loss/gain (-/-)

Present Illness
headache/dizziness(-/-), sore throat(-), C/S/R(-/-/-), dry mouth(-),
History
HEENT polydipsia(-), Ptosis(-), diplopia(-), dysarthria(-), dysphagia(-), anosmia(-),
Review of System

Physical Examination
orthostatic dizziness(-), visual hallucination(-)
Initial Lab Findings
Chest pain (-), Dyspnea (-), Orthopnea (-), Palpitation (-), Hemoptysis
Diagnosis & Plan Chest
(-)
Operation

GI A/N/V/C/D (-/-/-/-/-), Abdominal pain (-), Melena/Hematochezia (-/-)

F/U/N/D(-/-/-/-), hematuria(-), urinary incontinence(-) foamy urine(-),


GU
oliguria/polyuria(-/-)

Neuromuscular weakness(-), arthralgia(-), myalgia(-), joint stiffness(-)


PHYSICAL EXAMINATION
CASE
PRESENTATION

Identification Vital Sign BT 37.2 HR 78 RR 20 BP 126/84


Chief Complaint

Present Illness General 158.1cm, 53.7kg


History Appearance mental: alert, cooperative
Review of System

Physical Examination
HEENT Anemic conjunctiva(-), Icteric sclera(-), Tongue dehydration(-)
Initial Lab Findings

Diagnosis & Plan Chest Symmetric chest expansion, Normal breath sound
Operation

Abdomen Distension(-), Normoactive bowel sound

Extremity Rash(-), Pitting edema(-)


CASE
XR Chest PA [22.07.12]
PRESENTATION

Identification

Chief Complaint

Present Illness

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
CASE
Chest CT [22.07.20]
PRESENTATION

Identification

Chief Complaint

Present Illness

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
CASE
Chest CT [22.07.20]
PRESENTATION

Identification

Chief Complaint

Present Illness

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
CASE
Chest CT [22.07.20]
PRESENTATION

Identification

Chief Complaint

Present Illness

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
PET-CT [2022.07.20]
CASE
PRESENTATION

Identification

Chief Complaint

Present Illness

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
PET-CT [2022.07.20]
CASE
PRESENTATION

Identification

Chief Complaint

Present Illness

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
Bone scan [2022.07.25]
CASE
PRESENTATION

Identification

Chief Complaint

Present Illness

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
Brain MRI [2022.08.03]
CASE
PRESENTATION

Identification

Chief Complaint

Present Illness

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
PCNB
CASE
PRESENTATION

Identification

Chief Complaint

Present Illness

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
EBUS-TBNA
CASE
PRESENTATION

Identification

Chief Complaint

Present Illness

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
Diagnosis & Plan
CASE
PRESENTATION
▪ Diagnosis
Identification

Chief Complaint ✔ Chest CT


Present Illness

History
• LUL 2.9cm nodule
Review of System
✔ PET-CT
Physical Examination

Initial Lab Findings • a moderately hypermetabolic nodule in LUL with fissural retraction (3.99)
Diagnosis & Plan

Operation
• an isometabolic nodule or LN in the Rt highest mediastinum

✔ CT guided percutaneous needle biopsy

• adenocarcinoma

-> r/o Adenocarcinoma, Left upper lobe


Diagnosis & Plan
CASE
PRESENTATION

Identification ▪ TNM staging : cT1cN0M0 -> Stage IA3


Chief Complaint

Present Illness

History

Review of System

Physical Examination EBUS-TBNA : (-)

Initial Lab Findings

Diagnosis & Plan

Operation
Diagnosis & Plan
CASE
PRESENTATION

Identification ▪ Plan
Chief Complaint

Present Illness ✔ TNM staging : T1N0M0 -> Stage IA3


History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
Pre-op check up
CASE
PRESENTATION

Identification ▪ Nutritional status : good


Chief Complaint

Present Illness ▪ Performance Status


History

Review of System
✔ ECOG 0
Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
Pre-op check up
CASE
PRESENTATION

Identification ▪ Cardiac function


Chief Complaint

Present Illness
✔ HTN / 병동 BP 126/84~77 HR 78 : stable
History
✔ EKG [10/11] : normal sinus rhythm
Review of System

Physical Examination
✔ 2D ECHO 미시행
Initial Lab Findings

Diagnosis & Plan ✔ Tx: ARB, clopidogrel(10/16~ cut 7DA)


Operation
Pre-op check up
CASE
PRESENTATION ▪ Respiratory function
Identification
✔ Respiratory symptom (-)
Chief Complaint

Present Illness ✔ Chest X-ray [10/5] : improved pleural effusion since 9/18/22
History

Review of System
✔ Chest CT [9/19] :
Physical Examination
• Subsegmental atelectasis in left lingular segment and BLL.
Initial Lab Findings

Diagnosis & Plan • LN enlargement in right retrotracheal area; D/D Metastatic, decreased enhancement.
Operation
• Small pleural effuion in both, increased. RUL ant segment 에 이전 CT [2020/12/30] 에
비해 크기 증가

✔
PFT FEV1 2.31L (97%), FVC 2.85 (92%) FEV1/FVC 81% DLCO 19.6 (111%)

pH 7.39 – PCO2 33 mmHg - PO2 186 mmHg – HCO3- 20.0 mmol/L –


ABGA
CASE
PRESENTATION
Operation [22.10.24]
Identification  Surgery Report
Chief Complaint

Present Illness ■ 수술 전 진단명 ■ 수술소견 & 검체소견


History
Lung cancer, Left Upper Lobe - Preop. WH0/ECOG: 1, Karnofsky score: 85
- Preop. TNM: T2aN0M0
Review of System
■ 수술 후 진단명 - Mild pleural adhesion
Physical Examination
Lung cancer, Left Upper Lobe - No pleural effusion
Initial Lab Findings - Complete fissure
Diagnosis & Plan ■ 수술명 - Tumor was located just next to LLL
Operation Lobectomy of lung, RLL, robotic surgery -> wedge resection of LLL to get enough
Robotic LULobectomy with MLND resection margin
(2 ports, 3 arms)
■ 마취종류
* 마취종류 : General
CASE
PRESENTATION
Operation
Identification  Surgery Report
Chief Complaint
■ 수술방법 ■ 수술추가정보
Present Illness
- One-lung ventilation
History - Left lateral position · 수술 중 혈액 손실 : 300cc 미만
- 4cm working port at 8th ICS, 12mm port at 7th ICS
Review of System · 수술 중 특이 합병증 : No
- 8mm scope and 8mm trocar insertion at working port
Physical Examination
- Cardiere forcep insertion at 8mm port and Marryland forcep
· 외상으로 인한 수술 : No
Initial Lab Findings and Endowrist stapler at 12mm port · Tissue to path: Yes
Diagnosis & Plan - wedge resection of LLL to get enough resection margin with · Drain: Yes
Endodowrist stapler 1ea
Operation
- Superior pulmonary vein division with Endowrist stapler 1ea
- LUL pulmonary artery division with Endowrist stapler 3ea
- LUL bronchus division with Endowrist stapler 1ea
- Complete mediastinal LN dissection
- Bleeding control with Surgiguard
- Air leak control with Beriplast
- ON-Q pain catheter and chest tube insertion
- Wound closure
Disease Review
lung cancer staging work-up
TNM Staging
TNM Staging
Treatment
Treatment
Reference
▪ Harrison’s Principles of Internal Medicine, 21th edition

▪ NCCN Guidelines Version 4. 2022, Non - small cell lung cancer

You might also like